1. ASSISTING PATIENTS with QUITTING

2. Released June 2000 Sponsored by the Agency for Healthcare Research and Quality of the U.S. Public Heath Service with Centers for Disease Control and Prevention National Cancer Institute National Institute for Drug Addiction National Heart, Lung, & Blood Institute Robert Wood Johnson Foundation www.surgeongeneral.gov/tobacco/ CLINICAL PRACTICE GUIDELINE for TREATING TOBACCO USE and DEPENDENCE

3. EFFECTS of CLINICIAN INTERVENTIONS Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS. 1.0 1.1 (0.9,1.3) 1.7 (1.3,2.1) 2.2 (1.5,3.2) n = 29 studies Compared to smokers who receive no assistance from a clinician, smokers who receive such assistance are 1.7–2.2 times as likely to quit successfully for 5 or more months.

4. Tobacco users expect to be encouraged to quit by health professionals. Screening for tobacco use and providing tobacco cessation counseling are positively associated with patient satisfaction (Barzilai et al., 2001). Barzilai et al. (2001). Prev Med 33:595–599. Failure to address tobacco use tacitly implies that quitting is not important. The CLINICIAN’s ROLE in PROMOTING CESSATION

5. ASK ADVISE ASSESS ASSIST ARRANGE The 5 A’s Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS. HANDOUT

6. The 5 A’s (cont’d) Ask about tobacco use “Do you ever smoke or use any type of tobacco?” “I take time to ask all of my patients about tobacco use—because it’s important.” “Medication X often is used for conditions linked with or caused by smoking. Do you, or does someone in your household smoke?” “Condition X often is caused or worsened by smoking. Do you, or does someone in your household smoke?” ASK

7. The 5 A’s (cont’d) tobacco users to quit (clear, strong, personalized, sensitive) “It’s important that you quit as soon as possible, and I can help you.” “I realize that quitting is difficult. It is the most important thing you can do to protect your health now and in the future. I have training to help my patients quit, and when you are ready, I will work with you to design a specialized treatment plan.” ADVISE

8. The 5 A’s (cont’d) Assess readiness to make a quit attempt ASSESS Assist with the quit attempt Not ready to quit: provide motivation (the 5 R’s) Ready to quit: design a treatment plan Recently quit: relapse prevention ASSIST

9. Arrange follow-up care ARRANGE The 5 A’s (cont’d) Number of sessionsEstimated quit rate* 0 to 112.4% 2 to 316.3% 4 to 820.9% More than 824.7% * 5 months (or more) postcessation Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS. PROVIDE ASSISTANCE THROUGHOUT THE QUIT ATTEMPT

10. The 5 A’s: REVIEW ASK about tobacco USE ADVISE tobacco users to QUIT ASSESS READINESS to make a quit attempt ASSIST with the QUIT ATTEMPT ARRANGE FOLLOW-UP care

11. Faced with change, most people are not ready to act. Change is a process, not a single step. Typically, it takes multiple attempts. HOW CAN I LIVE WITHOUT TOBACCO? The (DIFFICULT) DECISION to QUIT

12. HELPING SMOKERS QUIT IS a CLINICIAN’S RESPONSIBILITY THE DECISION TO QUIT LIES IN THE HANDS OF EACH PATIENT. TOBACCO USERS DON’T PLAN TO FAIL. MOST FAIL TO PLAN. Clinicians have a professional obligation to address tobacco use and can have an important role in helping patients plan for their quit attempts.

13. STAGE 1: Not ready to quit in the next month STAGE 2: Ready to quit in the next month STAGE 3: Recent quitter, quit within past 6 months STAGE 4: Former tobacco user, quit > 6 months ago ASSESSING READINESS to QUIT Patients differ in their readiness to quit. Assessing a patient’s readiness to quit enables clinicians to deliver relevant, appropriate counseling messages.

14. Former tobacco user Recent quitter Ready to quit Not ready to quit Relapse Not thinking about it Thinking about it, not ready For most patients, quitting is a cyclical process, and their readiness to quit (or stay quit) will change over time. Assess readiness to quit (or to stay quit) at each patient contact. ASSESSING READINESS to QUIT (cont’d)

15. IS a PATIENT READY to QUIT? Does the patient now use tobacco? Is the patient now ready to quit? Provide treatment The 5 A’s Promote motivation Yes No Did the patient once use tobacco? Prevent relapse* Encourage continued abstinence Yes No *Relapse prevention interventions not necessary if patient has not used tobacco for many years and is not at risk for re-initiation. Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS.

16. STAGE 1: Not ready to quit Not thinking about quitting in the next month Some patients are aware of the need to quit. Patients struggle with ambivalence about change. Patients are not ready to change, yet. Pros of continued tobacco use outweigh the cons. GOAL: Start thinking about quitting. ASSESSING READINESS to QUIT (cont’d)

17. STAGE 1: NOT READY to QUIT Counseling Strategies DON’Ts Persuade “Cheerlead” Tell patient how bad tobacco is, in a judgmental manner Provide a treatment plan DOs Strongly advise to quit Provide information Ask noninvasive questions; identify reasons for tobacco use “Envelope” Raise awareness of health consequences/concerns Demonstrate empathy, foster communication Leave decision up to patient

18. The 5 R’s—Methods for increasing motivation: Relevance Risks Rewards Roadblocks Repetition Fiore et al. (2000). Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: USDHHS, PHS. Tailored, motivational messages STAGE 1: NOT READY to QUIT Counseling Strategies (cont’d)

19. STAGE 1: NOT READY to QUIT A Demonstration CASE SCENARIO: MS. STEWART You are a clinician providing care to Ms. Stewart, a 55-year-old patient with emphysema. She uses two different inhalers to treat her emphysema. VIDEO #1

20. Ask about tobacco use Link inquiry to knowledge of disease Assess readiness to quit Aware of need to quit; not ready yet Advise to quit Discuss implications for disease progression “I will help you, when you are ready” STAGE 1: NOT READY to QUIT Case Scenario Synopsis

21. The clinician has Established a relationship Established herself as a resource Planted a seed to move patient forward Opened a door to facilitate further counseling STAGE 1: NOT READY to QUIT Case Scenario Synopsis (cont’d)

22. Ready to quit in the next month Patients are aware of the need to, and the benefits of, making the behavioral change. Patients are getting ready to take action. STAGE 2: Ready to quit GOAL: Achieve cessation. ASSESSING READINESS to QUIT (cont’d)

23. Assess tobacco use history Discuss key issues Facilitate quitting process STAGE 2: READY to QUIT Three Key Elements of Counseling

24. STAGE 2: READY to QUIT Assess Tobacco Use History Praise the patient’s readiness Assess tobacco use history Current use: type(s) of tobacco, brand, amount Past use: duration, recent changes Past quit attempts: Number, date, length Methods used, compliance, duration Reasons for relapse

25. Reasons/motivation to quit (or avoid relapse) Confidence in ability to quit (or avoid relapse) Triggers for tobacco use What situations lead to temptations to use tobacco? What led to relapse in the past? Routines/situations associated with tobacco use STAGE 2: READY to QUIT Discuss Key Issues When drinking coffee While driving in the car When bored or stressed While watching television While at a bar with friends After meals During breaks at work While on the telephone While with specific friends or family members who use tobacco

26. “Smoking gets rid of all my stress.” “I can’t relax without a cigarette.” There will always be stress in one’s life. There are many ways to relax without a cigarette. THE MYTHS STRESS MANAGEMENT SUGGESTIONS: Deep breathing, shifting focus, taking a break. Smokers confuse the relief of withdrawal with the feeling of relaxation. STAGE 2: READY to QUIT Discuss Key Issues (cont’d) THE FACTS Stress-Related Tobacco Use

27. Patients who receive social support and encouragement are more successful in quitting. ADVISE PATIENTS TO DO THE FOLLOWING: Ask family, friends, and coworkers for support, for example, not to smoke around them and not to leave cigarettes out Talk with their health care provider Get individual, group, or telephone counseling STAGE 2: READY to QUIT Discuss Key Issues (cont’d) Social Support for Quitting

28. HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada All rights reserved. Most smokers gain fewer than 10 pounds, but there is a wide range.

29. Discourage strict dieting while quitting Recommend physical activity Encourage healthful diet, planning of meals, and inclusion of fruits Suggest increasing water intake or chewing sugarless gum Recommend selection of nonfood rewards Maintain patient on pharmacotherapy shown to delay weight gain Refer patient to specialist or program STAGE 2: READY to QUIT Discuss Key Issues (cont’d) Concerns about Weight Gain

30. Most pass within 2–4 weeks after quitting Cravings can last longer, up to several months or years Often can be ameliorated with cognitive or behavioral coping strategies Refer to Withdrawal Symptoms Information Sheet Symptom, cause, duration, relief Most symptoms peak 24–48 hours after quitting and subside within 2–4 weeks. HANDOUT STAGE 2: READY to QUIT Discuss Key Issues (cont’d) Concerns about Withdrawal Symptoms

31. Discuss methods for quitting Discuss pros and cons of available methods Pharmacotherapy: a treatment, not a crutch! Importance of behavioral counseling Set a quit date Recommend Tobacco Use Log Helps patients to understand when and why they use tobacco Identifies activities or situations that trigger tobacco use Can be used to develop coping strategies to overcome the temptation to use tobacco STAGE 2: READY to QUIT Facilitate Quitting Process HANDOUT

32. Continue regular tobacco use for 3 or more days Each time any form of tobacco is used, log the following information: Time of day Activity or situation during use “Importance” rating (scale of 1–3) Review log to identify situational triggers for tobacco use; develop patient-specific coping strategies STAGE 2: READY to QUIT Facilitate Quitting Process (cont’d) Tobacco Use Log: Instructions for use

33. Discuss coping strategies Cognitive coping strategies Focus on retraining the way a patient thinks Behavioral coping strategies Involve specific actions to reduce risk for relapse STAGE 2: READY to QUIT Facilitate Quitting Process (cont’d) HANDOUT

34. Review commitment to quit Distractive thinking Positive self-talk Relaxation through imagery Mental rehearsal and visualization Cognitive Coping Strategies STAGE 2: READY to QUIT Facilitate Quitting Process (cont’d)

35. Thinking about cigarettes doesn’t mean you have to smoke one: “Just because you think about something doesn’t mean you have to do it!” Tell yourself, “It’s just a thought,” or “I am in control.” Say the word “STOP!” out loud, or visualize a stop sign. When you have a craving, remind yourself: “The urge for tobacco will only go away if I don’t use it.” As soon as you get up in the morning, look in the mirror and say to yourself: “I am proud that I made it through another day without tobacco.” Cognitive Coping Strategies: Examples STAGE 2: READY to QUIT Facilitate Quitting Process (cont’d)

36. Control your environment Tobacco-free home and workplace Remove cues to tobacco use; actively avoid trigger situations Modify behaviors that you associate with tobacco: when, what, where, how, with whom Substitutes for smoking Water, sugar-free chewing gum or hard candies (oral substitutes) Take a walk, diaphragmatic breathing, self-massage Actively work to reduce stress, obtain social support, and alleviate withdrawal symptoms Behavioral Coping Strategies STAGE 2: READY to QUIT Facilitate Quitting Process (cont’d)

37. Provide medication counseling Promote compliance Discuss proper use, with demonstration Discuss concept of “slip” versus relapse “Let a slip slide.” Offer to assist throughout quit attempt Follow-up contact #1: first week after quitting Follow-up contact #2: in the first month Additional follow-up contacts as needed Congratulate the patient! STAGE 2: READY to QUIT Facilitate Quitting Process (cont’d)

38. Actively trying to quit for good Patients have quit using tobacco sometime in the past 6 months and are taking steps to increase their success. Withdrawal symptoms occur. Patients are at risk for relapse. STAGE 3: Recent quitter GOAL: Remain tobacco-free for at least 6 months. ASSESSING READINESS to QUIT (cont’d)

39. HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada All rights reserved.

40. STAGE 3: RECENT QUITTERS Evaluate the Quit Attempt Status of attempt Ask about social support Identify ongoing temptations and triggers for relapse (negative affect, smokers, eating, alcohol, cravings, stress) Encourage healthy behaviors to replace tobacco use Slips and relapse Has the patient used tobacco at all—even a puff? Medication compliance, plans for termination Is the regimen being followed? Are withdrawal symptoms being alleviated? How and when should pharmacotherapy be terminated?

41. Congratulate success! Encourage continued abstinence Discuss benefits of quitting, problems encountered, successes achieved, and potential barriers to continued abstinence Ask about strong or prolonged withdrawal symptoms (c hange dose, combine or extend use of medications) Promote smoke-free environments Social support Discuss ongoing sources of support Schedule additional follow-up as needed; refer to support groups STAGE 3: RECENT QUITTERS Facilitate Quitting Process Relapse Prevention

42. Tobacco-free for 6 months Patients remain vulnerable to relapse. Ongoing relapse prevention is needed. STAGE 4: Former tobacco user GOAL: Remain tobacco-free for life. ASSESSING READINESS to QUIT (cont’d)

43. HERMAN ® is reprinted with permission from LaughingStock Licensing Inc., Ottawa, Canada All rights reserved.

44. STAGE 4: FORMER TOBACCO USERS Assess status of quit attempt Slips and relapse Medication compliance, plans for termination Has pharmacotherapy been terminated? Continue to offer tips for relapse prevention Encourage healthy behaviors Congratulate continued success Continue to assist throughout the quit attempt.

45. READINESS to QUIT: A REVIEW Recent quitterNot ready to quitFormer tobacco user Quit date Ready to quit - 30 days+ 6 months Promote motivation The 5 R’s Behavioral counseling Pharmacotherapy The 5 A’s Behavioral counseling Relapse prevention Behavioral counseling Pharmacotherapy Relapse prevention

46. Routinely identify tobacco users (ASK) Strongly ADVISE patients to quit ASSESS readiness to quit at each contact Tailor intervention messages (ASSIST) Be a good listener Minimal intervention in absence of time for more intensive intervention ARRANGE follow-up Use the referral process, if needed COMPREHENSIVE COUNSELING: SUMMARY

47. Brief interventions have been shown to be effective In the absence of time or expertise: Ask, advise, and refer to other resources, such as local programs or the toll-free quitline 1-800-QUIT-NOW BRIEF COUNSELING: ASK, ADVISE, REFER This brief intervention can be achieved in 30 seconds.

48. WHAT IF… a patient asks you about your use of tobacco?

49. Courtesy of Mell Lazarus and Creators Syndicate. Copyright 2000, Mell Lazarus.

50. The RESPONSIBILITY of HEALTH PROFESSIONALS It is inconsistent to provide health care and —at the same time— remain silent (or inactive) about a major health risk. TOBACCO CESSATION is an important component of THERAPY.

51. DR. GRO HARLEM BRUNTLAND, FORMER DIRECTOR-GENERAL of the WHO: “If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claiming to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked.” USDHHS. (2001). Women and Smoking: A Report of the Surgeon General. Washington, DC: PHS.